Futterman-Collier, et al. Pacific Health Dialog. Vol. 4 ...

3 downloads 48 Views 549KB Size Report
Painting by Valerie Hunton. Artists collection. Reproduced with permission. ... Rex Hunton, MBChB, FRACP. BOOK REVIEW EDITOR. Greg J. Dever, MD, FAAP.
Congratulations... You have a paper from a back issue of

Pacific Health Dialog

Journal of Community Health and Clinical Medicine for the Pacific

ISSN: 1015-7867 This paper is © Resource Books Ltd, New Zealand. All rights reserved. This paper has been made available for the personal use of the person downloading it, who may store the original PDF locally; and it may be be cited, or reproduced in part, in professional publications. However this paper may not be fully reproduced anywhere, stored in any retrieval system other than the above, or made available on the internet or an intranet, or be transmitted in any form or by any means including by email, electrical, mechanical, photocopying, recording, digital or otherwise, without the prior written permission of Resource Books Ltd. New Zealand Institutions: Use Copyright Licensing Ltd for reproduction rights for class sets and any other reproductions. International Institutions: Contact us for our very reasonable prices for reproduction rights.

Resource Books Ltd www.resourcebooks.co.nz [email protected]

ORIGINAL PAPERS

PACIFIC HEALTH DIALOG. VOL 4. NO. 1

Perceptions of the social, cultural, and psychological well–being in Palau ANN FUTTERMAN–COLLIER, PH.D. * KATHLEEN SADAO, ED.D. * CALEB OTTO, M.H.A., M.B.B.S. * ANTHONY POLLOI, M.O. *

munities can manifest itself in negative health outcomes and is often associated with loss of indigenous cultural traits and values. Psychologists have come to recognize the importance of considering cultural and social change agents in the context of positive health outcomes of native peoples1,2,3 . For example, studying culture and mental health of communities emphasizes the need to explore individual acculturation levels along with ethnic identity when attempting to describe psychological indicators for personal quality of life satisfaction and community cohesion4. In addition, Abstract acculturative stress has been shown to influence the health To capture the social, cultural, and psychological aspects of and well–being of native peoples1,2,3,5. Recent studies underthe well–being of Palau, this study examined community taken in Hawaii6,7 and the Republic of Palau8 have examined satisfaction with the Campbell Community Survey (CCS). community satisfaction and the extent to which modernizaThe CCS contains 100 statements that are answered on a six– tion impacts the health and well–being of the community. point scale, where respondents indicate how much they When examining variables influencing acculturative trends, agree or disagree with each item. Subjects were Palauan ethnic identity, and psychological status, the multidimenhealth care professionals and high school students, and sional models are most effective. Due to the limited effort to American expatriates. The health care professionals and high study cultural change and the influence on Pacific communischool students reported that a feeling of belonging, a sense ties, a research initiative to identify community indicators of pride in their traditions and incorporating a comprehenheritage, and an appreciation sive approach is warranted. “ ... acculturative stress has for their geographic location been shown to influence the and beautiful surroundings, The people of Palau, like were the most important many Pacific nations, are parhealth and well–being of strengths in their community. ticularly vulnerable to rapid native peoples. ” While the expatriate group economic, political, and sodididentify geographiclocale cial reform. The purpose was as one of the Palau’s major strengths, they were more similar to gather the perceptions of community members about the to the adult Palauans when identifying weaknesses in the community in which they reside. The profile of their percepcountry: serious problems with alcohol and drugs, lack of tions will form a foundation of satisfaction variables that will urban services, and lack of recreational activities. In suppleassist the researchers in assessing the unique cultural, sociomental CCS questions specific to Palau, all groups indicated logical, and psychological factors influencing this culture in that Palauan customs have evolved into stressful obligations, transition. and that alcohol problems, substance abuse in women, domestic violence, and poor educational preparation and A survey method developed by psychologist David career opportunities for youth, are of serious concern. The Campbell was selected to assess community satisfaction in findings are discussed in terms of assets and weaknesses the Palau.9,10 A qualitative approach was used to identify the community has to build upon as well as issues to explore in potential factors influencing community cohesion in this greater depth. study. The Campbell Community Survey (CCS) is an assessment device that was designed to provide a set of comprehensive, versatile, standardized measuring scales for use in Introduction assessing the opinions and attitudes of community residents For decades, anthropologists have recognized that ecotoward their neighborhoods and communities. It provides a nomic development in traditional, subsistence style–comuseful medium for community members to articulate areas where the country needs social, emotional, physical, and economic reform. Areas evaluated by the CCS include * Ministry of Health, PO Box 6027, Koror, Republic of Palau education, health services, a sense of belonging, safety, and

28

PACIFIC HEALTH DIALOG VOL 4. NO. 1 recreational activities (see Table 1). The overall goal of the study was to provide a common language that could be used to encourage specific interventions, ultimately leading to improvement in the perceived quality of community life.

ORIGINAL PAPERS

Table 1. CCS Scales Scale Affordability

Excessive financial constraints on families as the cost of customs continues to increase without concomitant increases in salaries place undue burden on the employed family members.

Belonging

Due to the collective nature of this society, Palauans have lived for centuries within a Environmental Protection well defined family unit and clan structure. The Republic of Palau is an archipelago of Clan lands are still available today where Financial Optimism more than 200 islands situated in the far members are allowed to build their homes Freedom from Drugs southwestern corner of the Northern Pacific and live within the designated land area for Ocean. Palau has a total land mass of 188 the clan without leasing or purchasing the Freedom from Pollution square miles and while there are over 200 land. Neighborhood communities used to Geography islands that are part of Palau, only 9 are include groups of family and clan members permanently inhabited. The 7.1 square mile that communally shared resources. Conflict Health Care Services island of Koror is the Republic’s administraresolution was the responsibility of the chiefs Housing tive, and economic capital, with over 70% of chosen or assigned to rule the particular clan the population10, the total population of or village. With the shift from subsistence to Innovation Palau is 17,679 (1995 mid–decade census cash economy, Palauans have begun to live Leadership data). in communities that are more heterogeneous than in times past. The rural areas remain Pride Palau remained culturally isolated until the more intact but in the urban center of Koror Recreational Opportunities first recorded European contact (in 1783). economic factors have greatly influenced the Over the past century, Palau has been occuchange in the social fabric of the area. MemSafety pied by Spanish (1886–1899), German bers from different clans began obtaining Serenity (1899–1914), Japanese (1914–1944), and leases in Koror within villages that previously American (1944–1994) colonizers. On wereoccupiedbyKororclans. Neighborhood Tolerance October 1, 1994, Palau became an autonoor “hamlet” in Koror no longer refers to a Urban Services mous nation under a compact of Free Assohomogeneous grouping of clan members. ciation with the United States of America This sociological shift from a communal apGeneral Optimism (USA). proach to life to one of individualism, as Overall Index characterized by the emphasis on single Palau was traditionally comprised of sevfamily units, may have negative social results eral competing chiefdoms.11 The society was characterized which could be reflected in the increase in crime and abuse by a system of strong, ascribed hierarchical social ranking of both people and property. Villages can no longer be where the matrilineal descent determined social position, characterized by family and clan affiliations. inheritance, kinship structure, residence, and land tenure11. Since Western contact, dramatic political, economic, and Methods technological development changes have occurred as the country has begun to face painful issues associated with The CCS has been administered to approximately 1300 economic development and modernization. Because tradiindividuals in a wide range of communities including samples tional society still plays an important function throughout the of American homeless, rural community residents, leaderentire strata of the contemporary Palauan society, there are ship groups, municipal employees, neighborhoods in transiidiosyncraticblendsofthetraditionalandWesternapproaches tion, and “typical” communities. In addition, the CCS has that are seen today11. For example, many Palauan men and been administered to several non–American samples includwomen are employed in wage–labor jobs, but both sexes ing Australia, Canada, Latvia, and Taiwan. Campbell (1996) continue to rely on a subsistence economy where men fish reports appropriate reliability and validity coefficients, as well and women farm taro, tapioca, and potatoes. Another as statistically significant intercorrelations between items on example is that customary exchanges of bead monies and the scale10. foods (usually referred to as customs or siukang) occur at times of life crisis or transitions (such as deaths, births, The CCS contains 100 statements designed to elicit reassuming of titles, buying of homes). However, instead of sponses from community residents about topics relevant to relying solely on traditional money and food exchanges, community life. Respondents use a six–point scale to these customs have evolved to include American currency indicate how much they agree with each statement. The 100 and Western foods. These material changes in Pacific items are then categorized into 19 scales, each measuring a cultures occur as a predecessor to actual cultural changes12. different aspect of thecommunity, plus an overall index. Each

Background

Educational Programs

29

ORIGINAL PAPERS scalecontainsbetweenthreeand eight items, with a median of five items per scale. For scoring purposes, items that were rated “strongly agree” or “agree” were consideredpositive,and“strongly disagree”or“disagree”wereconsidered negative. Thus, items answered as “slightly agree” or “slightly disagree” were not counted. The CCS scales evaluate the following areas: Affordability, Belonging,EducationalPrograms, Environmental Protection, Financial Optimism, Freedom From Drugs, Freedom From Pollution, Geography, Health Care Services, Housing, Innovation, Leadership, Pride, Recreational Opportunities, Safety, Serenity, Tolerance,UrbanServices,and General Optimism (see Table 1).

PACIFIC HEALTH DIALOG. VOL 4. NO. 1 they have a great deal of exposure to Palauan citizens on a daily Our family relies heavily on traditional Palauan foods basis. It was hoped that their (e.g., taro, tapioca, fish, etc.). professional experience would provide them with insight about Palauan customs are important to me. issues that the average person I know women who have serious alcohol problems. faces, as well as the basis for Most young people that leave Palau don't return because making finediscriminations about the country’s assets and liabilities. there are too few career opportunities. Highschoolseniorswereselected If I had a difficult emotional or family problem, I would because census projections estiseek the services of the Behavioral Health Division. mate that 44% of the population There are people in my hamlet who are physically abused are currently 24 years or younger, by their spouses. anditwasthoughtthattheywould have both youthful perspective I would like to see changes in the financial obligations and the educational background expected in Palauan customs. necessary to make more sophistiOur children are well prepared for education overseas. cated evaluations of their country. Finally, expatriates were choDrinking alcohol leads to mental disease. sen to provide an “outside” perIf I had emotional or family problems, I would seek the spective on Palau. The authors advice of respected family or clan elders. hoped that the expatriates, particularly Americans, would provide a useful template for comparison. Table 2. CCS Supplemental Items

1 2 3 4 5 6 7 8 9 10

The administration instructions of the questionnaire were modified so that the meaning of neighborhood, neighbor, and community could be specified in a culturally sensitive way. Neighborhood was defined as: “the hamlet that you live in most of the time” (not necessarily your home state). Neighbor was defined as: “the clan or non–family members that live in the general area you live in, or within walking distance of you”. Community was defined as: “multiple hamlets, or, the largest metropolitan area around you that is your town or municipality”. Subjects were also told that “Unless you were asked otherwise, please refer to the residence that you have lived in most of the time over the past year when answering these questions”. CCS Palauan–Specific “Supplemental” Items. Ten supplemental questions were added to the CCS so that the authors could ask Palauan community members about issues germane to them. These tenquestions were presented and answered in the same format as the original CCS questions9 (see Table 2). Study sample. For the present study,healthcareprofessionals, high school seniors, and expatriates served as subjects. Health care professionalswereselectedbecause

The purpose of the CCS is to provide qualitative feedback by selected community members about a given community. As such, a minimum sample size of 30 per group is recommended10. Random selection of subjects is less important than careful selection of individuals who are motivated to accurately describe their community10. All respondents were given the option of remaining anonymous.

Health care professionals. Thirty–three Palauan health care professionals served as subjects. The Public Health Director at the Ministry of Health, who is a Palauan, was consulted about who should participate. He indicated that subjects should be distributed evenly amongst Palauan physicians, nurses and administrators. At the time of the study, there were 13 Palauan physicians and all participated at the Table 3. CCS demographic summary Director’s written request. The Health care Students Expatriates ChiefofNursingandtheHealth Services Administrator, also n=33 n=32 n=30 Item Palauans, each selected ten individuals who showed excelFemale 23 (69%) 10 (30%) 14 (47%) lent leadership skills. All nursMarried 28 (84%) 3 (10%) 19 (69%) ing and administrative participants that were asked to parSingle Family Dwelling 28 (84%) 25 (79%) 18 (59%) ticipate did. Questionnaires In Palau more than 3 yrs 29 (87%) 32 (100%) 12 (41%) were administered on a Monday and all health care profesCollege Graduate 26 (79%) 0 (0%) 29 (96%) sionals returned them by the Palauan Race 33 (100%) 32 (100%) 0 (0%) deadline five days later. Questionnaires were collected by a Live in Koror 18 (56%) 32 (100%) 26 (86%) Palauan assistant. Average Age

45

30

19

40

PACIFIC HEALTH DIALOG VOL 4. NO. 1 High school students. Instead of stratifying the small sample amongst each of Palau’s six high schools, the authors decided to administer the questionnaire to children in the public school system only. With the permission of their principal, a sample of 30 seniors at Palau High School participated in the study. Graduating seniors were given the option of completing the CCS in lieu of a portion of their final examination. Thirty students in a classroom of 44 chose to participate. They completed theCCSduringaregularclass period. Their American high school teacher administered and collected the questionnaires.

ORIGINAL PAPERS

Results

Table 4. CCS Scores for health care providers: high school students and expatriates Health Care

Students

Expatriates

Item

n=33

n=32

n=30

Affordability

48%

56%S

55%S

Belonging

58%S

61%S

39%W

Educational Programs

47%

55%S

37%W

Environmental Protection

47%

55%S

36%W

Financial Optimism

45%W

46%

42%

Freedom From Drugs

38%W

40%W

33%W

Freedom From Pollution

52%

49%

52%

Geography

55%S

50%

60%S

Health Care Services

49%

50%

49%

Housing

47%

47%

47%

Innovation

53%

59%S

42%

Leadership

47%

58%S

40%

Scale scores for the three groups were generated, translated into T–scores, and reported for comparative purposes. In general, the profiles exhibited a depressed impression of the community. The Overall Index for the high school seniors were the most optimistic (52%), followed by the health care professionals (46%), and then the expatriates (38%) (see Table 4). Health care professionals. From Table 3, 69% of the healthcareprofessionals were female (n=23). The majority of individuals were married (84%; n=28). The average age of respondents was 45 years (range 21 to 60). Most respondentslivedinsinglefamilydwellings(84%;n=28),and, 87% (n=29) had been residing in Palau for over 3 years (range 1 to 30+ years). The sample was highly educated, where79% (n=26)had atleast graduatedfromcollege. Fifty– six percent (n=18) of the respondents reported living in the town of Koror.

47% 59%S 43% Expatriates. Thirty expatri- Pride ates served as subjects. All Recreational Opportunities 43%W 54% 38%W respondents,butoneFilipino Safety 51% 44%W 47% were American. The authors selected individuals who had Serenity 46% 46% 50% been in the community for at Tolerance 53% 49% 44% least one year and had frequent daily interactions with Urban Services 35%W 51% 25%W the Palauan community. General Optimism 52% 54% 45%W Thirty two individuals were actually asked to participate: Overall Index 46% 52% 38%W oneindividualcouldnotcomS = Strengths and W = Weaknesses plete the survey because of Highschoolstudents. Thirty Note: Scores were standardized. If a score falls between 44 and 54, it is percent (n=10) of the high an illness in her family; the considered "mid-range". If a score is greater than or equal to 55 it is other did not complete the school students were female. considered high, or a strength, and if a scores is less than or equal to 45 CCS within the one week Only 10% (n=3) of the indiit is considered low, or a weakness. time period indicated. The viduals were married. The completed surveys were colaverage age of respondents lected by two of the American authors (AF and KS). was 19. Most students lived in single family dwellings (79%; n=25), and 100% (n=32) had been residing in Palau for over Statistical analysis. CCS forms were computer scanned 3 years (range 4 years to entire life). Sixty–three percent and the data analyzed by David Campbell, at the Center for (n=20) of the respondents reported living in the town of Creative Leadership, Colorado Springs, Colorado using SPSS Koror. computer software for Windows. To permit exploration of scores from different scales, the raw scores on each scale Expatriates. Forty–seven percent (n=14) of the expatriates were converted to standard scores with the conventional were female. Sixty–three percent (n=19) of the individuals raw–score–to–standard–score conversion formula. A distriwere married. The average age of respondents was 41 (range bution of scores for each scale with a population mean of 50 21 to 60). The expatriate sample was highly educated, with and a standard deviation of 10 was produced. Scores of 55 96% (29) having received at least a college education. Most and above were considered “high,” or strengths, and scores respondents lived in single family dwellings (59%; n=18). of 45 and below were considered “low,” or weaknesses. Forty–one percent (n=12) had lived in Palau for over 3 years Difference scores between scales greater than 5 are consid(range 1 to 30 years; median 3.1 years). Eighty–six percent ered notable10. (n=26) of the respondents reported living in Koror. Table 4

31

ORIGINAL PAPERS

PACIFIC HEALTH DIALOG. VOL 4. NO. 1

shows the CCS scale percentages of the study groups.

Table 5. CCS Scores for Supplemental Items Health Care

Students

Expatriates

n=33

n=32

n=30

48%

86%

0%

85%

68%

13%

72%

86%

74%

48%

45%

49%

57%

86%

30%

54%

82%

29%

57%

45%

44%

Item

Palauan health care professionals. Foreach Family relies on Palauan foods of 20 scales evaluated, Palauan customs important 65% of the scales were Would like changes in financial reported as falling beobligations of Palauan customs low the average score. In order of severity, the Domestic violence occurs greatest problems identified were: lack of Ur- Know women with alcoholproblems ban services (e.g., good "Drinking alcohol leads to mental libraries, public transdisease" portation, fair newspaWould use Behavioral Health Services pers, theaters, museums, regular garbage Would seek advice of respected family or clan elders if needed collection); problems withillegaldrugsorFreeChildren well prepared for education dom From Drugs (e.g., overseas substantial problem Few career opportunities for young with drug dealers and people useofalcoholverycommon); lack of Recreational Opportunities (lack of parks, music, arts, walking and bicycling trails, active and varied night life); and lack of Financial Optimism.

of Recreational Opportunitiesasthenextgreatest weaknesses. For strengths, Geography and Affordability (cost of living is reasonable) were rated as Palau’s greatest assets. Palau Supplemental Items. Resultsindicated that community members are all concerned about a number of social issues in Palau (see Table 5).

First,Palauancustoms are still considered very important to most re12% n/a 7% spondents. However, over 70% of the respondents felt that the 66% 67% 74% financial obligations expected in the customs needed to change. Interestingly, while 68% the youth reported that customs were important, they also felt strongly (86%) that the customs were too expensive. 42%

The two strengths reported by the Palauan health care professionals were a sense of Belonging (roots in the community; good friends; close contact with relatives) and Geography (beautiful, scenic).

81%

18%

Second, there are serious concerns the respondents indicated about the educational programs and career opportunities offered in Palau. Only 12% of the health care professionals and 7% of the expatriates reported that the children in Palau were well prepared for higher education overseas when they graduate from high school. Both groups of adults also reported that many young people didn’t return to Palau after leaving because there are too few career opportunities (health care professionals=66%; expatriates=74%).

High school Students. The high school students were very optimistic about Palau, rating 65% of the scales as above the average score. Like both groups of adults, the students also reported that problems with drugs or Freedom From Drugs as one of the most important weaknesses. However, they then went on to identify feeling a lack of personal Safety (e.g., feeling safe in your neighborhood) as the next greatest problem. Unlike the adults, the students felt that Urban Services were satisfactory.

Third, all groups consistently reported that they knew of Palauan women who were victims of physical abuse by their spouses. There was less agreement about the extent of alcohol problems in women, where the high school students reported a great deal more (82%) followed by health care professionals (54%) and then expatriates (30%).

The two major strengths reported by the students were a sense of Belonging, followed by Pride (e.g., proud of the history and traditions) in their community.

Most of the respondents agreed that they would seek out psychiatric or psychological services from the Ministry’s Behavioral Health Division. Interestingly, the high school seniors were more likely to seek out assistance from clan elders (81%), the traditional approach for assistance, compared to health care professionals (42%). Surprisingly, the students (82%) and the health care professionals (54%) believed that drinking alcohol would cause mental illness, reflecting a commonly held belief we have heard from the general population. This belief was not strongly held by the expatriates.

Expatriates. For each of 20 scales evaluated, 80% of the expatriates’ scales were reported as falling below the average score. The expatriates identified the same two problems as those identified by the health care professionals as most significant, although they rated the scores lower. These were lack of Urban Services and again, problems with drugs, or Freedom From Drugs. The expatriates then identified poor Education (public schools receive strong support; schools are innovative; schools measure up to world standards), and lack

32

PACIFIC HEALTH DIALOG VOL 4. NO. 1

ORIGINAL PAPERS

Finally, the high school seniors were more likely to have Palauan foods as a major part of their diet (86%), compared to health care professionals (48%). None of the expatriates reported using Palauan foods on a regular basis.

tional giving of subsistence gifts and bead monies into multiple and complex cash and material giving obligations. These financial requirements are extremely stressful for most individuals and often result in a great deal of debt. There has been a trend in the Pacific to extend custom–giving obligations beyond immediate clan members and relatives into extended family, work and non–kin social networks3. Where belongingtoone’scommunityandculturemayallowPalauans to survive the pressures of modernization, the stress of increased customobligations may competewith this strength and manifest itself in increased stress–related problems and illnesses. The role of belonging and cash committed customs are interrelated variables that warrant further study.

Discussion The Palauan respondents, especially the high school student sample, indicated a feeling of belonging, a sense of pride in their traditions and heritage, and an appreciation of their geographic location and beautiful surroundings. Although immersed in a tide of shifting economic policies and developmental concerns, the Palauans in this study maintain a strong community satisfaction, cohesion, and ethnic identity. The Palauans recognize their home as a beautiful one that remains foremost in their everyday lives. Identifying this strength is linked to assuring the legacy for the benefit of future Palauans. The expatriate subgroup concurred with the Palauan groups on the beauty of Palau.

The lack of urban services and recreational opportunities was mentioned by the Palauan health professionals and expatriates in Palau as a deficit area. The foreigners’ responses in general, were expected to be different due to their sojourner status in Palau. Studies concerning culture shock and acculturation when entering and living in other cultures have demonstrated this finding.1 Although some similarities were evident such as the geographic excellence, adequate housing, and health care services, other areas may be affected by cultural differences in how Palau is perceived by an outsider. For example, the quality and quantity of educational opportunities are greater in the US. In addition, urban services and recreational opportunities are commonplace in the US in both urban and rural regions of the country. Palauans may not nor want to have adequate access to libraries, theaters, and museums, or spend free time in parks and recreational areas. It would be important to define the meaningofrecreationactivitiesandurbanservicesforPalauans and fully describe what Palauans would like to see improved in this area.

The maintenance of a culture and tradition, e.g., belonging, is a true indicator of the stability of a culture. On Lanai, a small island inHawaii, dramatic social changes were evident during the movement from an agriculture to tourism economic base. The community was originally entrenched in subsistence and traditional belief patterns that had been passed on through generations of Hawaiians6. Other Pacific Islands have seen increases in crime, delinquency, and substance abuse as a result of westernization13. Palauans also face social and cultural disruptions due to economic development factors and have the potential to be adversely affected. The feelings of belonging to and having pride for their community may be critical factors in the survival of the Palauan culture amidst the inevitable economic pressures that shift the priorities of community members. Identifying the strengths in a culture and community (i.e. belonging and pride) by involving community members allows the monitoring of development that occur at the community level.8 Because modernization and the social, cultural and psychological adjustments that inevitably occur have been linked to poor health outcomes in Pacific and Asian Americans3,4, the finding of belonging in this study may also be a positive indicator for Palauan health status. The impact of cultural identification on health status in Palau is an important topic for future investigation.

Alarming anecdotal information regarding the nature and extent of alcohol and other substance abuse in Palau has been circulating for at least 20 years. The perceived gravity of the situation in Palau has ranged from serious, to epidemic, to out of control. The subjects in the present study all identified problems with drugs and alcohol as the number one weakness facing the nation. From past reports in Palau, the substances in question have included tobacco, alcohol, marijuana, heroin and now include crystal methamphetamine (ICE). What has been clear throughout this era has been that the systems of prevention, treatment and rehabilitation have remained weak and ineffective. The causes of these drug and alcohol problems are many and unknown. Palau has recently begun a nation–wide assessment of drug and alcohol problems in order to determine the actual prevalence of substance abuse. With more reliable information, there will be a basis to plan and monitor the execution of strategies intended to ameliorate the negative impact of substance abuse on the society.

The way a Pacific person considers wealth and the distribution of wealth is dichotomous to metropolitan people.12 Pacific person share a collective viewpoint that contributing to the good of the group is most important; this is directly juxtaposed to an individualistic society’s emphasis that the single family unit, as a self–contained system, is most meaningful. Thetwo approaches towards living aredysynchronous and disharmonious, and potentially place undue burdens on extended family wage earners trying to satisfy both their customary role and the demands of their immediate families. Modern–day customs have evolved in Palau from the tradi-

There are some potential weaknesses in the design and methodology that could have influenced the overall results of

33

ORIGINAL PAPERS

PACIFIC HEALTH DIALOG. VOL 4. NO. 1

the study. First, interviewer bias is considered as a potential limitation to the results reported here. The surveys were distributed through the Ministry of Health. Respondents may have reported different answers if they were asked to complete the survey by a different Ministry (such as Justice), or their chief or village elders. The respondents may have inflated their opinions of some aspects of their communities, such as health care, for social desirability reasons, because that is what they thought was expected from them.

some of the potential limitations mentioned here and further the exploration of the impact of modernization on a newly developing nation.

Acknowledgement The authors wish to thank David Campbell for generously providing us with CCS and for analyzing the data as well as Ida Rekoi, Francisca Blailes and Joanna Polloi for administering the surveys.

Second, the survey instrument, although tested in other countries besides the US, was initially developed by American researchers to study western communities. The researchers of this study were cognizant of the potential cultural incongruities and language incompatibilities when revising the instrument for piloting in Palau. For example, the section on recreational activities may be culture bound. Respondents may have considered other community activities such as customs (events where families members and clans participate in funerals, first child birth, house purchases, and marriage ceremonies), community gatherings, and fishing and farming as recreational activities, not concerts, theaters, or parks. The authors recognize the potential limitations of the instrument in this regard. The tool was adapted to include 10 supplemental items concerning areas of relevance for Palauans and the individual responses were adjusted or clarified to correspond to local definitions and terminologies.

References

Thirdly, further piloting and refinements of the CCS would be suggested to avoid any cross–cultural biases or misinterpretations and improve upon the relevance of the tool for Palau. Because the subjects selected for the pilot study were predominantly from the urban center of Koror, potential cultural biases may have been lessened due to the respondents increased exposure to western ways. The design of the instrument was not changed in order that a cross–country comparison could be achieved. Finally, English is the second language for most native Palauan speakers. English is the preferred language of the educational curriculum although Palauan vernacular is the language used for verbal communication. The instrument was not translated into Palauan due to the nature of the research tool. The researchers chose to survey Palauans in their second language to keep the survey instrument standardized, and maintain the conceptual meaning of items presented.

1.

Berry JW, Kim U, Power S, Young M and Bujaki, M. Acculturation attitudes in plural Societies. Applied Psychology: An International Review, 1989; 38: 185–206.

2.

Chin–Hong PV and McGarvey, ST. Lifestyle incongruity and adult blood pressure in Western Samoa. Psychosomatic Medicine, 1996; 58: 130–137.

3.

Hanna JM and Fitzgerald MH. Acculturation and symptoms: a comparative study of reported health symptoms in three Samoan communities. Social Science Medicine, 1993; 36(9): 1169–1180.

4.

Nagata DK. Assessing Asian American acculturation and ethnic identity: the need for a multi–dimensional framework. Asian American and Pacific Islander Journal of Health, 1994; 2(2): 109–124.

5.

Berry JW and Kim U. Acculturation and mental health. In Health and Cross–Cultural Psychology. PR Dasen, JW Berry, and N Sartorius (editors), Newbury Park, CA; Sage Publications: 1988; 10: pp. 207–236.

6.

Matsuoka J. Laa’I: Community on the Threshold of Change. School of Social Work, University of Hawaii; Hawaii: 1990

7.

Matsuoka J. Lana’i: A Longitudinal Study of Economic Development and Social Change. School of Social Work, University of Hawaii, National Institutes of Mental Health Grant; Hawaii: 1996.

8.

Matsuoka J, Sadao K, Sadao L, and Renguul N. Peleliu: A Study of Lifestyle and Mental Health in a Rural Palauan Community. School of Social Work, University of Hawaii, National Institutes of Mental Health Grant; Hawaii: 1996.

9.

Campbell D. Campbell Community Survey. Center for Creative Leadership, Colorado Sprigs, Colorado: 1995

10. Campbell D. Manual for the Campbell Community Survey. Center for Creative Leadership, Colorado Springs, Colorado: 1996. 11. Watson B, Larson K, and Sadao K. An Introduction to the Republic of Palau. Asian American and Pacific Islander Journal of Health, 1994; 2 (3): 257–258.

The pilot study holds promise in supporting local efforts to maintain the rich cultural heritage of Palauan communities while redesigning the financial burden perceived from custom obligations. The study provides an indication that the drug issue is at a critical stage and strategies to ameliorate the problem needs to be a primary focus of prevention and treatment programs. Further piloting of the instrument with different subgroups under different conditions may alleviate

12. Nero KL. The hidden pain: drunkenness and domestic violence in Palau. Paper presented to ASAO Symposium; Domestic Violence in the Pacific; Texas: 1989. 13. Ravuvu A. Cultural heritage and healthy development. Pacific Health Dialog, 1995; 2(1): 90–97. 14. Adinkrah M. Crime, Deviance and Delinquency in Fiji. Suva, Fiji; Star Printery Limited: 1995. •

34

Pacific Health Dialog

Pacific Health Dialog Journal of Community Health and Clinical Medicine for the Pacific March 1997 Volume 4. Number 1.

Medical Education and Health Reform A PUBLICATION OF PACIFIC BASIN MEDICAL OFFICERS TRAINING PROGRAM (UNIVERSITY OF HAWAII) THE

THE

FIJI SCHOOL OF MEDICINE

PACIFIC BASIN MEDICAL ASSOCIATION THE

Pacific Health Dialog Journal of Community Health and Clinical Medicine for the Pacific Volume 4. Number 1. March 1997 Copyright © 1997. Pacific Health Dialog / Resource Books ISSN 1015–7867 EDITOR ASSOCIATE EDITOR BOOK REVIEW EDITOR ABSTRACT EDITOR PHD MANAGER

Sitaleki A. Finau, MBBS, DComH, FAFPHM Rex Hunton, MBChB, FRACP Greg J. Dever, MD, FAAP Annette Sachs–Robertson, DSM, MPH Peter Biggs, BSc.

The editors for this issue were Dr Sitaleki Finau, Senior Lecturer, Department of Maori and Pacific Health, School of Medicine at Auckland University, Auckland, New Zealand and Dr. Gregory Dever, Director, Micronesian Human Resource Development Centre, Pohnpei, Federated States of Micronesia.

Pacific Health Dialog is published twice a year for the Pacific Basin Medical Officers Training Program (University of Hawaii), the Fiji School of Medicine and the Pacific Basin Medical Association (PBMA). The views and opinions expressed in PHD do not necessarily reflect those of the editorial staff, the Advisory Board, the University of Hawaii, the Fiji School of Medicine or the PBMA. This issue was produced with the financial assistance of the United Kingdom ODA, Pacific Aid Management Office, Fiji. The views expressed in this issue do not necessarily reflect UK Overseas Development Administration policies. All editorial communications to: PHD Editor Department of Maori and Pacific Health Faculty of Medicine and Health Sciences University of Auckland Private Bag 92019, Auckland, New Zealand Phone: (+64) 9–373–7599 Fax: (+64) 9–373–7074 email: [email protected] All subscriptions, advertising and enquiries to: PHD Manager Resource Books Ltd P.O. Box 25–598 Auckland, New Zealand Phone: (+64) 9–575–8030 Fax: (+64) 9–575–8055 email: [email protected] website: www.resourcebooks.co.nz See inside back cover for subscription information. Cover: ‘Medical Student Percy’ from the series ‘PACIFIC BASIN MEDICAL OFFICERS TRAINING PROGRAMME’. Painting by Valerie Hunton. Artists collection. Reproduced with permission.

Pacific Health Dialog Volume 4. Number 1. March 1997

Contents Guest Editorials J. I. Samisoni, P. Head, S. A. Finau, G. Dever ........................ 5 Original Papers Risk factors associated with preterm deliveries in Pohnpei, 1995 S. Malsol, J. A. Flear ..................................................................... 9 Ke Ola O Hawaii - a community partnership for health, and new challenges for faculty G. Feletti, C. Lum .................................................................... 14 Problem-based learning: its application to medical rehabilitation research M. H. Fitzgerald, D. A. Goebert, D. Tipene–Leach, G. Dever ................................................................................... 22 Perceptions of the social, cultural, and psychological well–being in Palau A. Futterman–Collier, K. Sadao, C. Otto, A. Polloi ............. 28 The influence of bed nets on Bancroftian Filariasis in Buhutu Valley, Papua New Guinea P. Sapak, G. Williams ............................................................. 35 Efficacy of yeast-recombinant hepatitis B vaccine in prevention of perinatal transmission in Saipan A. M. Durand, H. Sabino Jr., F. Mahoney, I. Abraham ....... 39 Family planning and contraception in Tongoleleka village, Kingdom of Tonga H. Ivarature ............................................................................. 43 Community perceptions of Youth to Youth in Health: a peer education program for primary health care, Marshall Islands K. L. Braun, D. Keju–Johnson ................................................ 51 Evaluating interagency collaboration in disability programs in the Pacific Basin K. Sadao, N. Robinson, P. Magrab ........................................ 57 Cancer in Guam: a review of death certificates from 1971 – 1995 R. L. Haddock, C. L. Naval .................................................... 66 Obstetric emergencies and maternal deaths in the Solomon Islands C. Fallon, V. Johnston, K. Thomas, A. Larson, J. Pikacha .... 78 Case Reports and Short Communications The PBMA and telemedicine in the Pacific: the first steps V. Yano, S. A. Finau, G. Dever, D. A. Person, J. I. Samisoni, W. Baravilala, J. Malani .................................... 81 Blood lead levels among children in Pohnpei: preliminary results I. Vimoto, S. A. Finau ............................................................. 85 Conference Reports and Papers Dietary genocide: eating to an early death in Micronesia R. Jackson ............................................................................... 88 Medical education in the Pacific J. I. Samisoni ............................................................................ 90 The role of medical associations The Honourable Del Pangelinan ......................................... 93 The PBMOTP - towards an inspirational accomplishment E. K. Pretrick ........................................................................... 94 Pay attention to your education and work and see how much you can add to life V. M. Yano ............................................................................. 99

A dream fulfilled J. Flear .................................................................................... 101 One of the most precious realities: the quiet and private satisfaction of duty faithfully done T. A. Rogers ........................................................................... 104 Internet medical education resources B. J. Goldsmith ...................................................................... 105 Summary of the reports of the First, Second, and Third Pacific conferences of Community Health in Medical Education, 1991-1996 A. Sachs–Robertson, J. Flear, S. A. Finau, G. Dever .......... 106 Family planning in the Federated States of Micronesia: past and present E. K. Pretrick .......................................................................... 111 Training the Pacific surgeon C. McRae .............................................................................. 113 Viewpoints and Perspectives The health crisis in the US associated Pacific islands: moving forward A. Diaz .................................................................................. 116 Health reform in Trinidad and Tobago: lessons for the Pacific islands? J. Sancho ............................................................................... 130 Early experiences of the Health Planning Unit in Fiji J. Pepperall, G. Teskey ......................................................... 138 Appropriate health workforce for sustainable development in the Pacific S. A. Finau ............................................................................. 143 Teenage pregnancies in the Pacific: a Tongan’s perspective S. F. Katoanga ....................................................................... 154 Challenges for Pacific nutritionists J. Tunidau–Schultz ................................................................ 161 Nutrition training: needs and priorities in the Pacific Meleófa Malolo ................................................................... 166 The case for a Pacific public health surveillance network M. J. O’Leary ......................................................................... 172 Book Reviews ............................................................................. 175 Pacific Health Institutions The Pacific medical education model: introducing the process of innovation G. Dever, S. A. Finau, R. Hunton ........................................ 177 Coordinating study skills in medical education: the PBMOTP experience D. Wyatt ............................................................................... 191 The evolution of community health training at the PBMOTP J. A. Flear ............................................................................... 198 Distance Education for health workers in Micronesia M. M. Fochtman, C. B. Allen, R. Gurusamy ....................... 203 The Office of Pacific Health and Human Services J. Iser ...................................................................................... 207 Journal Abstracts ....................................................................... 210 News ............................................................................................ 215 Index to previous issues ........................................................... 220 Editorials ..................................................................................... 223